Endocrine emergencies: integrated approach — structured clinical encounter

A 4-year-old girl is brought to the emergency department with two weeks of polyuria, polydipsia and weight loss attributed to a viral illness, and is now vomiting with deep sighing breathing. Bedside glucose is 28 mmol per litre, venous pH 7.08, bicarbonate 8 mmol per litre, beta-hydroxybutyrate 5.2 mmol per litre, corrected sodium 137 mmol per litre. She is drowsy but rousable. Four hours into treatment she develops a headache and becomes drowsier with a heart rate of 60 and a blood pressure of 130 over 90. You are the paediatric registrar working through the recognition, the resuscitation, the cerebral-oedema complication and the family conversation.